Clinical history
questionnaire

New adult patients · Sikoloji an Kreyòl

This questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Please complete it as honestly and completely as possible. All information you provide is confidential, as required by law.

ConfidentialYour information is protected.
Take your timeYou can go back to previous steps to make corrections.
DurationAbout 20–30 minutes.

Personal and contact information

Please fill in this information accurately.

Personal information

Full name * Date of birth * Age Sex * ID document (national ID, passport, CIN/NIF...) (optional) Marital status *

Contact information

Cell phone * Home / alternate phone Email

Country * Department / State / Province City * Home address * Zip code

Household and family

Please share information about your children and the people you live with.

Children

Do you have children? * Yes No

Who currently lives in your residence? (adults and children)

I live alone

Name	Relation	Sex	Age

Current concerns and goals

Tell us what brings you to seek support today.

In your own words, describe the current problems as you see them * 0/1000 How long has this been going on? * What made you come in at this time? * 0/500

What do you hope to gain from this evaluation and/or counseling? * 0/500 If you had difficulties in the past, what have you done to cope? Was it helpful? 0/500

Symptoms

Please check any symptoms or experiences you have had in the last month.

Safety

Thoughts about harming or killing yourself Thoughts about harming or killing someone else Self-mutilation / cutting

Sleep

Difficulty falling asleep Difficulty staying asleep Difficulty getting out of bed Not feeling rested in the morning

Average hours of sleep per night

Eating and weight

Are you trying to lose weight? Weight gain (lbs) Weight loss (lbs)

Thinking and memory

Difficulty concentrating or thinking Large gaps in memory Flashbacks Nightmares

Perception

Feeling outside yourself, detached, observing what you are doing Feeling puzzled as to what is real and unreal Persistent, repetitive, intrusive thoughts, impulses or images Unusual visual experiences (flashes of light, shadows) Hearing voices when no one else is present Feeling that your thoughts are controlled or placed in your mind Feeling that the television or radio is communicating with you

Sexual orientation Heterosexual Homosexual Bisexual I choose not to answer

Please describe any other symptoms or experiences you have had problems with:

Treatment and medication

Share your experience with previous mental health treatment.

Previous therapy

Have you seen a counselor, psychologist, psychiatrist or other mental health professional before? * Yes No

CURRENT psychiatric medication

Are you currently taking psychiatric medication? * Yes No

CURRENT non-psychiatric medication

Are you currently taking non-psychiatric medication? * Yes No

PAST psychiatric medication

Have you been on psychiatric medication in the past? * Yes No

Hospitalization

Have you been hospitalized for psychiatric reasons? * Yes No

Suicide attempt

Have you ever attempted suicide? * Yes No

Medical history

This information helps us provide safer care.

Are you CURRENTLY under treatment for any medical condition? * Yes No

List any PRIOR illnesses, operations and accidents:

Family history

Information about your parents, siblings and mental health in your family.

Father

Age

Status

Living Deceased

Occupation Health Frequency of contact Are you / have you been close to them?

Mother

Age

Status

Living Deceased

Occupation Health Frequency of contact Are you / have you been close to them?

Brothers and sisters

Name	Sex	Age	Whereabouts	Are you close?

Childhood

During your childhood, did you live any significant period of time with anyone other than your natural parents? Yes No

Mental health in the family

Check the appropriate box if these are or have been present in your relatives.

	Children	Brothers	Sisters	Father	Mother	Uncle / Aunt	Grandparents
Nervous problems
Depression
Hyperactivity
Counseling
Psychiatric medication
Psychiatric hospitalization
Suicide attempt
Death by suicide
Drinking problem

Past marital history

Have you been married previously? Yes No

Social history

Your education, work, religion and social life.

Education

Highest level completed Degree obtained

Did you have any disciplinary problems in school? Yes No

Were you considered hyperactive / ADHD in school? Yes No

What kinds of grades did you get in school?

Military service

Have you served in the military? Yes No

Employment

Are you currently employed? * Yes No

Employment history (most recent first)

Type of job	Dates	Reason for leaving

Legal

Have you ever been arrested? Yes No

Substance use

Your answers remain confidential and help us plan better care for you.

Other drugs

Please answer for each drug listed below.

Drug	Ever used?	Age of first use	Time since last use	Approx. use in last 30 days
Marijuana
Cocaine
Crack
Heroin
Methamphetamine
Ecstasy

Life events (Holmes-Rahe Scale)

Check each event that has occurred in your life in the last two (2) years. There are no right or wrong answers.

Your total score: 0

Is there anything else you would like us to know about you?

Consent, review and submit

Please read this information and review carefully before submitting the form.

Review your information

Electronic signature *

By signing and submitting this form, you confirm that the information provided is correct to the best of your knowledge.

Click here to sign

Date *